Diabetes mellitus is a disorder caused by insufficient or non
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1 The Economic Burden of Diabetes Mellitus in the WHO African Region Introduction Diabetes mellitus is a disorder caused by insufficient or non production of the hormone insulin by the pancreas. There are two types of diabetes mellitus. Type 1 diabetes (previously known as insulin-dependent or childhood-onset), the more severe form characterized by a lack of insulin production, usually first appears in young people under the age of 35 years and most commonly between the ages 10 and 16. Type 2 diabetes (formerly known as non-insulin-dependent or adult-onset) characterized by the body s ineffective use of insulin develops mainly among people over WHO estimates that more than 180 million people worldwide have diabetes. 2 An estimated 2.9 million people die from diabetes, i.e. case fatality rate of In the year 2000, the prevalence of diabetes in the WHO African Region was about 7 million people. Out of these, about 0.7 million (10%) had Type 1 diabetes and 6.3 million (90%) had Type 2 diabetes mellitus. About people died of diabetes; were permanently disabled; and experienced temporary disablement. Diabetes exerts a heavy economic burden on society. This burden is related to health system costs incurred by society in managing the disease, indirect costs resulting from productivity losses due to patient disability and premature mortality, time spent by family members accompanying patients when seeking care, and intangible costs (psychological pain to the family and loved ones). This study attempts to estimate the economic burden of diabetes in the WHO African Region. Methods and data The study uses diabetes mellitus prevalence estimates for 2000 from the WHO web site. 2 The distribution by age from Murray and * Dr Joses Muthuri Kirigia Lopez 4 was used to disaggregate the total number of people with diabetes into age groups. The Gross Domestic Product per capita per year was obtained from a World Bank publication. 5 The prices of drugs were obtained from the WHO Regional Office for Africa 6 and the hotel component of hospital costs (i.e. excluding medicines and diagnostic tests) were obtained from the WHO web site. 7 Figure 1 indicates the three alternative approaches for estimating economic burden of a public health problem like diabetes. These include the willingnessto-pay approach, 8 the macroeconomic/ production function approach 9 and the cost-of-illness. 10 This study employed the latter approach. (See Figure 1 for a conceptual framework of the economic burden of diabetes.) The economic burden of diabetes equals direct cost plus indirect cost. Direct cost equals diagnostic cost plus cost of medicines (insulin and oral drugs) plus cost of devices for injecting insulin (insulin pen, refill cartridge, needles) 49
2 plus cost of outpatient consultation plus cost of hospitalization plus household direct costs (including transport costs). Indirect cost equals value of productive time lost due to premature mortality plus permanent disability plus temporary disability plus time of family caregivers (include those accompanying patients to health facilities). Figure 1: Economic burden of diabetes conceptual framework Willingness-to-Pay Approach Direct Cost C os t-of-illnes s Approach (debility, morbidity & mortality) Economic Burden of Diabetes Indirect Cost Measurement approaches Intangible cost Pain & suffering Macroeconomic / Production Function Approach RESULTS Direct costs Cost of medicines Table 1 presents estimates of the cost of medicines used to treat diabetes patients in the WHO African Region. It was estimated that diabetics needed insulin, i.e. all the Type 1 patients plus 5% of the Type 2 patients. It was estimated that 15.4 billion IU of insulin would be needed per year to treat all the abovementioned diabetics in a year. Multiplying that quantity by unit cost of insulin obtains the total annual cost of US$ 36.2 billion. It was estimated that the devices for delivering insulin would cost US$ million per year. Household Prevention costs, e.g. exercise, diet Treatment costs, e.g. transport, user fees Other health care access costs (e.g. bribes) Organi zation & Operation of Health System Prevention, e.g. health education Medicines (insulin, oral drugs) Hotel costs (HRH time, utilities, food, ma terials, equipment, building space) Diagnostic costs (HBA1c test, lipid profile, proteinuria test, blood sugar, test, electrocardiogram) Other costs Short-term Cost Value of productive time lost due to diabetes Indirect Cost Premature mortality Permanent disability Temporary disability Time of family care givers It was estimated that 80% of total population with Type 2 diabetes used oral diabetes drugs. A total of about 9 billion 500mg metformin tablets would be consumed in a year. Multiplying that quantity of drugs by unit price per tablet gives a total cost of oral drugs of US$ million per year. Adding the cost of insulin, devices for delivering insulin and oral drugs obtains the total annual cost of medicines of US$ 36.3 billion. 50
3 Table 1: Estimation of cost of medicines used to treat diabetes patients in the WHO African Region Insulin (A) Number of people with Type 1 702,000 (B) 5% of people with Type 2 diabetes 351,000 (C) Total number in need of insulin (A+B) 1,053,000 (D) Annual use of IU (40IU per day) for each patient taking insulin 14,600 (E) Total quantity of insulin needs (IU) per year [C x D] 15,373,800,000 (F) Cost of insulin (per IU) US$ 2.36 (G) Total number of devices for delivering insulin per year [C x 365 days] 384,345,000 (H) Cost of device (syringe) US$ (I) Total annual cost of insulin & devices for delivery [(E x F)+(G x H) US$ 36,339,358,536 Oral drugs (J) 80% of total population with Type 2 diabetes using oral drugs 5,967,000 (K) Number of tablets taken per person per year 1,500 (L) Total number of tablets needed per year [J x K] 8,950,500,000 (M) Cost per tablet US$ 0.02 (N) Total cost of oral drugs [L x M] US$ 152,606,025 Cost of consultations and hospitalization Table 2 presents estimates of the cost of outpatient department (OPD) consultations and hospitalization. It was assumed that all the people with diabetes would make four visits in a year to a hospital outpatient department. Thus, multiplying the number of diabetics by four visits yields a total of 28.1 million OPD visits. In turn, multiplying that total number of OPD visits by cost per outpatient visit gives the total OPD consultation cost of US$ million per year. It was assumed that all the patients with Type 1 diabetes plus 5% of patients with Type 2 diabetes (i.e million patients) would require one hospitalization per year. Multiplying that with the average length of stay of nine days gives a total of 9.6 million inpatient department days (IPD) per year. A further multiplication of IPD by unit cost per bed day yields a total cost of hospitalization of US$ million per year. 51
4 Cost of diabetes tests Table 2: Consultations and hospitalizations Cost of OPD consultations (A) Total number of diabetics 7,020,000 (B) Number of OPD medical visits per patient per year 4 (C) Total number of OPD visits [A x B] 28,080,000 (D) Cost per outpatient visit US$ 5.24 (E) Total OPD Cost [C x D]= US$ 147,186,000 Cost of hospitalizations (F) Total number of patients hospitalized (Type 1+ 5% of Type 2)= 1,053,000 (G) Average length of stay in days = 9.08 (H) Total number of IPD days [F x G] 9,561, (I) Unit cost per bed day at levels 1, 2 & 3 hospitals US$ (J) Total cost of hospitalization [H x I] US$ 223,887,329 Table 3 shows the cost of diabetes tests. It was estimated that in a year all the people with diabetes would require one HBA1c test, one lipid profile, one proteinuria test and one electrocardiogram. The average cost of those tests was obtained from a private hospital in a Member State. The annual total cost of diabetes diagnostic tests was estimated at US$ million. Item Table 3: Cost of diabetes tests (A) Total number of people with diabetes 7,020,000 (B) Cost of one HBA test US$ (C) Cost of one lipid profile US$ (D) Cost of one electrocardiogram US$ (E) Cost of one proteinuria test US$ 9.21 (F) Cost of blood sugar test US$ 5.56 (G) Total cost of diabetes-related tests per person per year US$ (H) Total cost, diabetes-related tests all people [A x G] US$ 524,828,571 52
5 Household travel costs related to diabetes care Table 4 depicts estimates of the transport costs incurred by patients and people accompanying them to health service providers. It was assumed that each patient would be accompanied by one family member and would make a total of four visits in a year. Multiplying 56.2 million return trips to the service provider per year by travel cost per return trip would yield total travel costs of about US$ million. Indirect costs Cost of premature diabetesrelated mortality Table 5 shows the information used to estimate cost of diabetes-related premature mortality in the WHO African Region in Out of the total number of 7.02 million people with diabetes, about (1.6%) of them died from the disease. The death of persons within the economically-productive age group (15 years and above) resulted in a loss of 1.05 million productive years of life (PYL). Multiplying those productive years of life lost by GDP per capita yielded a total economic loss of US$ million due to premature diabetes mortality; this is equivalent to US$ 5191 per diabetes death. Table 4: Household travel costs related to diabetes care Items (A) No. of diabetics 7,020,000 (B) No. of persons travelling 2 (C) No. of hospital/health centre visits in a year 4 (D) Total number of return trips to the service provider per year [A x B x C] 56,160,000 (E) Return transport cost per trip US$ 2.70 (F) Total travel cost [ D x E] US$ 151,632,000 Table 5: Cost of diabetes-related premature mortality in the WHO African Region Item Population (A) Total no. of people with diabetes mellitus 7,020,000 (B) No. of people with Type 1 diabetes mellitus [A X 0.1]* 702,000 (C) No. of people with Type 2 diabetes mellitus [A X 0.90]* 6,318,000 Mortality (D) Deaths related to diabetes [A X ]** 113,100 (E) No. of deaths, persons aged years [D x 0.08]** 9,048 (F) No. of deaths, persons aged years [D x 0.16]** 8,096 (G) No. of deaths, persons aged 60 & above [D x 0.6]** 67,860 (H) No. of productive life years lost (PLYL) by persons aged years 30 (I) No. of PLYL, persons aged years (J) No. of PLYL, persons, aged 60 years & above 7.18 (K) Total PLYL, persons aged (E x H) 272, (L) Total PLYL, persons aged (F x I) 289, (M) Total PLYL, persons aged 60+ (G x J) 486, (N) Grand total no. of PLYL (K+L+M) 1,049, (O) GDP per capita per year US$ 470 (P ) Total cost (N x O) US$ 493,137,489 (Q) Cost per productive person death [P/(E+F+G)] US$ 5,191 * See Ref. 3, Roglic et al. ** See Ref. 4, Murray and Lopez. 53
6 Cost of diabetes-related permanent disability Table 6 presents estimates of the cost of diabetes-related permanent disability in the WHO African Region. In 2000 there were approximately people permanently disabled by diabetes in the Region. Out of those, approximately 0.05% were 0 4 years; 0.05% were 5 14 years; 15.45% were years; 34.25% were years; and 50.20% were 60 years and above. Thus, 99.9% of the permanently disabled diabetics are within the economically-productive age bracket. Murray and Lopez estimated that the diabetics in sub-saharan Africa in the Region diabetics aged years spend on average a duration of 30 years in permanent disability; the years spend 16 years; and those aged 60 years and above spend 7 years in permanent disability. This translates into years of permanent disability among persons aged years; years of permanent disability among persons aged years; and years of permanent disability among persons aged 60 and above. Adding the three preceding statistics obtains the grand total of 7.72 million years of permanent disability among the diabetics within the economically-productive age bracket. Since permanent disability implies that the victims cannot participate in their economic activities for life, multiplying the grand total years of permanent disability by average GDP per capita per year yields a total cost of US$ 3.63 billion. The productivity loss per economically-active person was US$ 6464 per year. Table 6: Cost of diabetes-related permanent disability in the WHO African Region Permanent disability (A) No. permanently disabled by diabetes = 561,600 (B) Persons permanently disabled [A x ]* 86,741 (C) Persons permanently disabled [A x ]* 192,344 (D) Persons 60+ permanently disabled [A x ]* 281,943 (E) Years of permanent disability, year age group (F) Years of permanent disability, years age group (G) Years of permanent disability, persons 60 & above years 7.18 (H) Total years of permanent disability per person aged years [B x E] 2,610,897 (I) otal years of permanent disability per person aged years [F x C] 3,082,319 (J) Total years of permanent disability per person aged 60 & above years [D x G] 2,022,943 (K) Grand total years of permanent disability [H+I+J] 7,716,159 (L) GDP per capita per year US$ 470 (M ) Total Cost [K x L] US$ 3,626,594,698 (N) Cost per person permanently disabled [M/(B+C+D)] US$ 6,464 * See Ref. 4, Murray and Lopez. 54
7 Cost of diabetes-related temporary disability Table 7 summarizes cost of diabetes-related temporary disability in the WHO African Region. In 2002, there were approximately people with temporary disability. It was assumed that the duration of temporary disability was four days per diabetic per year; which is equivalent to the number of times a diabetes patient is likely to make a hospital or health centre consultation. It was estimated that 99.9% of the people temporarily disabled by diabetes were within the economically-activity age group. Multiplying the total number of patients aged 15 years and above by four days of temporary disability gives total days of temporary disability. Multiplying 25.8 million by GDP per capita per day of US$ 1.81 yields an economic loss due to temporary disability of US$ 46.7 million. The cost per person of temporary disability due to diabetes was US$ Productivity loss of caregivers Table 8 presents an estimate of the value of productivity time lost by family members accompanying their diabetic loved ones to health services providers. Usually patients are accompanied by one (or more) family members (or a friend) when going to seek treatment. In this study it was assumed that the patient would be accompanied by one person during each of the four visits. Multiplying the number of diabetics by the number of accompanying persons and by the number of health facility visits yielded 28.1 million productive days lost in a year. It was estimated that society loses a minimum of US$ 50.8 million per year from the time spent by family members accompanying their diabetic loved ones to health service centres. Table 7: Cost of diabetes-related temporary disability in the WHO African Region Temporary disability (A) No. of persons temporarily disabled by diabetes = 6,458,400 (B) Persons aged temporarily disabled [A x ]* 997,519 (C) Persons aged temporarily disabled [A x ]* 2,211,961 (D) Persons aged 60+ temporarily disabled [A x ]* 3,242,347 (E) Days temporarily disabled per person per year 4 (F) Persons aged 15 44, temporarily disabled days [B x E] 3,990,075 (G) Persons aged 45 59, temporarily disabled days [C x E] 8,847,844 (H) Persons aged 60+ temporarily disabled days [D x E] 12,969,387 (I) Total days of temporary disablement [F+G+H] 25,807,306 (J) Daily GDP per capita US$ 1.81 (K) Total cost [I x J] US$ 46,651,669 (L) Cost per person temporarily disabled [K/(B+C+D)] US$
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